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1 t� F�' �v Y. `f 4.�1 � � � } ' <br /> Applications Will Be Processed When Submitted Properly Completed. Be Sure To b Th$ �1`1c9 tII% if Lt 'll `1f Ilr +Ij <br /> F013 OFF16E USE: APPLICATION n <br /> (For Non-Transferable, Revocable, Suspendable) p1J�114,-IZ�g�'WELt981 <br /> ENVIRONMENTAL HEALTH PERMIT J�3 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY SAN <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instal lthe work 04fefhdesdrila e)- hsjaPplication is <br /> made in compliance with SanJoaquin Count -O dinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address } a /O City/Town 41 ljjl ,, A./ _ <br /> Owner's Name E5 Phone <br /> Address , City <br /> Contractor's Namer License#pg &o Business Phone <br /> Contractor's Address T Emergency Phone _ISO iart-'P-- _ <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes �_ No <br /> TYPE OF WORK (CHECK): NEW WELL 13 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ I]l f <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 54 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done cl <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District., <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I wiI II for Grout ecti prior to grouting and a final inspect' c- <br /> Signed X F �- Title: _ � Date: - <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - ��l <br /> Application Accepted 8 Date 1 <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By to Date Inspection By Date <br /> Fee Is Due: C1 ANNUALLY El PER UNIT El PER SITE 11 EACH El January 1 &Received By January 31 <br /> ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE r <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 16 2T9 to <br /> Received by Otte t Receipt No. Permit No. I Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />